Ch 55 Deep Neck Infections (Bailey’s)

PROPER MANAGEMENT OF A DEEP NECK INFECTION BEGINS WITH SECURING THE AIRWAY
1. Etiology- Historically, MC from infections from tonsils and pharynx parapharyngeal space infection
a. ***Odontogenic infections (now the MC cause in adults): poor oral hygiene, low SES
b. Salivary gland infections
c. Penetrating trauma
d. Iatrogenic
e. Spread from superficial infections
f. Necrotic malignant nodes
g. Mastoiditis w/ resultant Bezold’s abscess
h. Acute rhinosinusitis in children retropharyngeal lymphadenitis suppuration of these LN
i. IV drug abuse risk of jugular vein and carotid sheath infections from contaminated needles
j. Congenital anomalies: thyroglossal duct cysts, branchial cleft anomalies Account for 10-15% of DNI in
children
k. Unknown
2. Superficial cervical fascia: platysma, superficial vessels, lymphatics, envelops muscles of facial expression, continuous w/ SMAS
3. Deep cervical fascia
a. Superficial layer of deep cervical fascia/investing cervical fascia: trapezius, SCM, parotid gland/fascia, submandibular gland,
muscles of mastication (MOM), forms the stylomandibular ligament
i. Stylomandibular ligament: separates parotid and submandibular glands; formed as investing fascia tracks anteriorly to
cover submandibular gland and MOM
ii. Suprasternal space of Burns: formed as investing fascia surrounds intermediate tendon of omo
1. Contains: LN, vessel bridging 2 anterior jugs
iii. “Rule of 2’s” regarding contents of investing fascia: 2 suprahyoids (masseter, anterior belly of DG), 2 muscles that
cross the neck (SCM, traps), 2 salivary glands (parotid, submandibular), 2 fascial spaces (parotid, masticator)
b. Middle layer of DCF
i. Muscular division of middle DCF: strap muscles
ii. Visceral division of middle DCF: parathyroid glands, thyroid gland, esophagus, trachea, larynx, pharyngeal
constrictors, buccinator
1. Pretracheal fascia
2. Buccopharyngeal fascia: posterior to esophagus, separating it from deep layer of DCF, continuous w/
pretracheal fascia
a. Marks the anterior border of retropharyngeal space
b. Buccinators, pharyngeal constrictors, and esophagus lie bw/ the pharyngobasilar fascia anteriorly
and buccopharyngeal fascia posteriorly
c. 2 raphes formed by the buccopharyngeal fascia:
i. posterior midline raphe: which attaches to alar layer of DCF
ii. Pterygomandibular raphe
c. Deep layer of DCF (Prevertebral fascia): composed of 2 parts:
i. Prevertebral division: cervical vertebra, phrenic n, paraspinous m; from skull base to coccyx, lateral and posterior
attachments to transverse spinous processes, respectively
ii. Alar division: from skull base to 2nd thoracic vertebra; separates retropharyngeal space anteriorly from danger space
posteriorly; covers the cervical sympathetic trunk which lies along this plane
1. A midline raphe connects alar division to buccopharyngeal fascia. This accounts for off-midline
presentation of retropharyngeal space infections
d. Carotid sheath: contributions from all 3 layers of deep cervical fascia: usual contents + sympathetic plexus, ansa cervicalis
4. Deep neck space anatomy: spaces classified based on their relationship to hyoid
a. Entire neck
i. Retropharyngeal space: from skull base to tracheal bifurcation
1. Medial to carotid sheath
2. Posterior to buccopharyngeal fascia
3. Anterior to alar fascia (part of deep layer of deep cervical fascia) which is anterior border of danger space
a. Midline raphe accounts for off-midline presentation of retropharyngeal space infections vs
danger space and prevertebral space infections which are usually midline
i. Main direct route of spread is from parapharyngeal space
4. Nodes of Rouviere: reside w/in this space; may cause abscess w/ sinus or nasopharynx infection in children
ii. Danger space: from skull base to diaphragm; loose areolar tissue w/ minimal resistance to spread of infection
1. Posterior to Alar fascia
2. Anterior to prevertebral fascia
3. Bounded laterally by transverse processes of vertebrae
4. Contains cervical sympathetic trunk
5. Sources of infectious spread: retropharyngeal, parapharyngeal, prevertebral spaces
iii. Prevertebral space: skull base to coccyx; dense areolar tissue
1. Anterior to vertebral bodies
2. Posterior to prevertebral fascia
3. Bounded laterally by transverse processes of vertebrae laterally (don’t let this confuse you)
 4. Contains: vertebral a, phrenic n, brachial plexus; paraspinous, prevertebral, and scalene m
5. Direct extension of infection from vertebrae (Pott’s abscess) or penetrating injuries
iv. Carotid space/visceral vascular space: from skull base to thorax; bounded by carotid sheath
1. Spread of infection is from parapharyngeal space, penetrating trauma, or IVDA
b. Suprahyoid
i. Parapharyngeal (PPS)/lateral pharyngeal/peripharyngeal/pharyngomaxillary space: hub for infectious spread
1. Inverted pyramid borders
a. Base/superior border: skull base
b. Apex/inferior: at greater horn of hyoid
c. Lateral borders: lateral pterygoid, mandible, parotid (deep lobe of parotid), medial pterygoid can also be lateral border
d. Medial: superior constrictor, levator and tensor veli palatine (all enveloped by middle DCF)
e. Anterior borders: medial pterygoid (involvement causes TRISMUS), pterygomandibular raphe
f. Posterior border: prevertebral fascia
2. Subdivided into pre-styloid and post-styloid compartments by styloid process
a. Pre-styloid: fatty tissue, styloglossus, stylopharyngeus, deep lobe of parotid, LN
i. Structures that course through: maxillary a, auriculotemporal n, inferior alveolar n,
lingual n
b. Post-styloid compartment: neurovascular structures (CN 9-12, sympathetic chain, carotid, IJV),
carotid space w/ its contents on its way to mediastinum
3. Infections that spread laterally communicate w/: masticator space
4. Inferior spread: submandibular space
5. Posterior spread: retropharyngeal space
ii. Submandibular and Sublingual spaces: communicate freely around posterior aspect of mylohyoid; submandibular
space freely communicates anteriorly w/ submental space, separated by anterior belly of digastric
1. Borders
a. Superior border: mucosa of floor of mouth
b. Posteroinferior border: hyoid bone
c. Anterior and lateral: mandible
d. Posterior: base of tongue
2. Sublingual space contents: CN 12, sublingual glands, Wharton duct
3. Submandibular gland found in both sublingual and submandibular spaces as it wraps around mylohyoid
iii. Parotid/parotidomasseteric space: investing cervical fascia envelopes: parotid, periparotid LN, CN7, posterior facial
veins, ECA
1. Fascia tightly adhere to parotid laterally resulting in difficulty DDx b/w cellulitis vs abscess in parotid space
on PhEx
2. Fascia is deficient along medial border allowing easy communication w/ prestyloid PPS
iv. Masticator space: extension of investing fascia; contents: masseter, medial and lateral pterygoids, body and ramus of
mandible, inferior alveolar vessels and n, buccal fat pad, temoporalis tendon
1. Subdivisions
a. Masseteric space: b/w mandibular ramus and masseter m
b. Pterygoid space: b/w mandibular ramus and pterygoid muscles
2. Anterolateral to PPS
3. Deep to temporal space
4. Infections of this space primarily from 3rd mandibular molar
v. Peritonsillar space: can extend to PPS
1. Medial border: palatine tonsillar capsule
2. Lateral: superior pharyngeal constrictor (pharyngobasilar fascia)
3. Anterior: palatoglossus m
4. Posterior: palatopharyngeus m
5. Inferior: posterior 3rd of tongue
vi. Temporal space:
1. Boundaries
a. Medial: squamous T-bone
b. Lateral: superficial temporal fascia
2. Subdivided into superficial and deep temporal spaces by temporalis m
3. Contents: maxillary a, V3
c. Infrahyoid
i. Anterior visceral space: from thyroid cartilage down to level of 4th thoracic vertebra
1. Contents: pharynx, esophagus, trachea, thyroid, parathyroids
2. MC portals of infection: anterior esophageal perf by trauma, FB, or iatrogenic
ii. Suprasternal space (of Burns): above sternal notch; enveloped by investing fascia
1. Contents: small LN, bridging vessels b/w anterior jugular veins